December 2, 2011

CANADA: With greying population, better integrated health care will be needed

TORONTO, Ontario / The Globe and Mail / Health / December 2, 2011

By Sheryl Ubelacker

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With the leading edge of the baby-boom generation turning 65 this year, Canada's health-care system will need to adjust its focus to meet the future needs of an ever-expanding population of seniors, a new report warns.

The report by the Canadian Institute for Health Information, released Thursday, shows that those in the 65-plus demographic are the most frequent users of health care, costing more than any other segment of the population.

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While representing 14 per cent of the population, seniors account for 40 per cent of hospital services and about 45 per cent of overall health spending. But by 2036, those aged 65-plus are expected to make up one-quarter of the country's population and claim an even bigger piece of the health-services pie.

While cost is an issue, the more critical concern is how to provide the best possible care to those who often have complex medical needs, said Kathleen Morris, CIHI's director of health system analysis and emerging issues.

“I think we're not worried that the system isn't sustainable,” said Morris, noting that the greying of the population appears to be having less effect on costs than once predicted.

“There is no question this growing group of seniors is going to have an impact on health care,” she said. “But when we take a look at the needs of seniors, we think the system will need to adapt or adjust to accommodate them.”

That will require more integrated care, an increased focus on prevention and adoption of new technology to improve efficiency, the report says.

Seniors often require care from different providers, including a family doctor, specialist and pharmacist; they may also be admitted to hospital, need home-care services or require transfer to a long-term care facility, the report points out. But often there is little or no co-ordination among the services, leading to patient frustration and gaps in care.

William Lawand, who at 79 is still working as a consultant to the chartered accountancy firm he co-founded more than 50 years ago, said the system works well when it comes to having an annual checkup, for example.

“What doesn't go well is when you try to make appointments with specialists,” Mr. Lawand said from Montreal. “For instance, if I get a little rash and I'm worried about it and I want to see a skin specialist, you might have to wait three months.

“It's too long to be able to get appointments with specialists. That is the real problem, and it's all specialists, not just dermatologists.”

Long waits in hospital emergency rooms are also difficult, especially for those 65 and up, he said. (The report shows seniors spend an average of 3.7 hours in the ER, compared with 2.7 hours for their younger counterparts before being admitted to hospital.)

Mr. Lawand said specially trained nurses and other health professionals could be providing some services performed by physicians. “There's too much routine work that has to go up to the doctors and that's why they get so backlogged.”

The report found that while 93 per cent of seniors are living in their own homes — where surveys show they want to be — research suggests seniors have better health if they receive “the right services at home,” explained Ms. Morris. Such services could go beyond visits from nurses and physiotherapists, for instance, to provision of transportation to doctors' appointments and even help shovelling snow.

The CIHI study also suggests better integration of services could help promote safer drug use in seniors. Two-thirds of Canadians 65 and up are taking at least five prescription medications; almost one in four are taking 10 or more.

“I think that sometimes brings up a challenge with the co-ordination of care,” said Ms. Morris. “Some of those prescriptions may be coming from a family doctor, others may be coming from a specialist, and we know that seniors tend to take a lot of over-the-counter or drug store medications ... and they could also be taking vitamin supplements.

“So one of the challenges is managing all those different medications,” including avoiding potentially dangerous drug interactions, she said.

Technology can help: large drug store chains have computerized patient records that can red-flag drugs that shouldn't be taken together, and there are even electronic gadgets that allow family members to check in remotely to ensure an aging loved one has taken all their pills.

But technology should play a much bigger role in the future, the report stresses, including electronic record-sharing that would allow access to patient information to providers across the system and reduce costly and wasteful duplication of tests and other services.

The report also emphasizes that prevention must take a higher profile in the care of those 65-plus, three-quarters of whom have a chronic health condition such as heart disease or diabetes.

“We know that initial prevention is critical,” said Morris, referring to a healthy lifestyle that includes a good diet and regular exercise. “But we also know that, where we're starting from today ... there's a different way of looking at prevention that keeps a condition from getting worse.”

Roughly half of Canadian seniors have high blood pressure. Uncontrolled or poorly managed blood pressure can lead to a heart attack or stroke that will require hospitalization and a possible disability leading to long-term care.

“So the dollars spent in terms of preventing an existing condition from getting worse are often dollars well-spent, for the system and for seniors, too, because it's keeping them where they want to be, which is at home,” she said.

Commenting on the report,Paul Katz of Baycrest said the health system needs to implement a model of care that focuses on the well-being of the individual patient.

“We can do this, we can keep people at home by the use of really smart care management, interdisciplinary teams, all with a focus on basic geriatric principles of care,” said Dr. Katz, chief of staff of the Toronto centre for the aging.

“The biggest barrier is the status quo,” he said, noting that health-care institutions tend to operate as separate entities as opposed to an integrated whole.

“We need to break apart those silos ... and spread accountability across the system. So when a patient is transferred from a hospital to a long-term care facility for rehabilitation, for example, the hospital should maintain responsibility. They should be partners with the nursing home in treating that particular individual.

“Right now, when the patients leave the door, the responsibility stops.”

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